Physical performance testing is completed with patients in order to collect data and make observations regarding the overall function of the limb integrated into the entire functional unit of the body, rather than specific clinical tests merely looking at the integrity of the involved body part/joint(s). Data is collected to draw limb to limb comparisons and comparisons between the subject and any existing normative data. Qualitative observations are made to comment on the level of control, ease, and efficiency with which the individual executes the task. This is useful for assessing the true return of function and the individual s risk for potential future injury. Testing Protocol 10 minute warm-up on the bike + brief stretching 1) Explain/demonstrate the physical task 2) Patient practices x 2 trials 3) Patient performs 3 testing attempts 4) Record the best of the 3 attempts 0-5 point perceived exertion scale: (0) very easy << >> (5) maximal exertion Return to Function (Level I): Core Stability With all core stability tests, the patient is asked to maintain a pose or perform repetitions of a task with special attention to postural alignment. The patient is allowed one verbal cuing episode to correct faulty alignment. Upon any additional cuing, the testing effort will be terminated and time/reps to failure is recorded at that point. *Poses can be modified from basic to advanced per level of fitness Prone Plank Hold Patient assumes the prone plank position with bilateral forearm and flexed toe support. Cue the patient to maintain level alignment from shoulders through the hips, knees, down to the ankles, maintaining a neutral spine/pelvic orientation without excessive lordosis. Patient holds this position, maintaining perfect plank alignment and height. Cue height with yard stick. Measurements Gathered: 1. Time to failure (Goal = 60 seconds) 2. Perceived exertion (0-5 point scale) Basic Advanced Page 1
Side Plank Hold Patient assumes the side plank position, with forearm support directly below the shoulder of the bottom arm, and foot support with feet stacked one on top of the other. Perfect linear alignment from the sternum down through the pubic symphysis to the ankles is to be achieved. Excessive forward rotation of the trunk or excessive lumbar lordosis is not permitted. Cue plank height with yard stick. Measurements Recorded: 1. Time to failure (Goal = 60 seconds) 2. Perceived exertion (0-5 point scale) Basic Advanced Single Leg Bridge Repetitions Patient lies supine with knees flexed to 100 and arms folded across the chest. The patient raises one knee to bring the femur to a vertical orientation with a comfortable degree of knee flexion. The patient performs a maximal single leg bridging effort with the height recorded and marked at the opposite hip with a measuring stick. The patient then begins repetitions of single limb bridging, achieving the peak height at each repetition with a steady tempo of 60 bpm (1 bridge per 2 seconds) not allowing for rest between repetitions or accelerated upward thrusting with a single effort. The patient is to maintain a neutral lumbar and pelvic orientation without excessive lordosis or contralateral pelvic collapse. Measurements Recorded: 1. Reps to failure (Goal = 20 reps) 2. Perceived exertion (0-5 point scale) Page 2
Return to Function (Level I): Balance Single Limb Balance Patient stands on one leg with both hands kept at the hips. This test may be performed with eyes open and/or eyes closed, depending on the competence level of the patient. The patient maintains his/her balance, with time stopping if the stance foot shifts position, if the opposite foot touches down, or if the arms wave off the hips. The patient performs 3 attempts and the maximal value is recorded. Measurement Recorded: Time to failure per leg (Maximum value = 60 seconds) Stand and Reach The patient stands at the apex of a 90 degree angle V taped onto the floor. Each line of the V is at a 45 off-set from the patient s neutral orientation. While standing on one leg with the foot along the neutral line, the patient lowers him/her toward the ground and reaches with the opposite hand out along one of the diagonals, attempting to touch as far out as possible, still being able to return back to standing without losing balance. One clean, controlled touch with a finger is allowed, without walking out on the fingers or bracing with the thumb. This is repeated along each diagonal for each leg (anteromedial, anterolateral), with the best of 3 attempts recorded. Measurement Recorded: Maximal distance obtained for each diagonal for each leg (centimeters) Anterior/Medial Reach Anterior/Lateral Reach Page 3
Return to Function (Level I): Muscular Strength Star Excursion Balance Test The patient stands with his/her toes at center of the Y grid taped onto the floor. Each posterior line of the Y is at a 45 off-set from the neutral angle of anterior arm of the Y. While standing on one leg the patient lowers him/herself toward the ground and reaches with the toes of the free leg out along one of the diagonals, attempting to touch as far out as possible WITHOUT allowing the heel of the stance leg to come off the ground. This is repeated along each line of the Y for each leg (anterior, posteromedial, posterolateral), with the best of 3 attempts recorded. Failure: 1) Losing balance/single limb support and touching down at any point during the lowering/raising motion, 2) Transferring body weight off the center leg onto the reaching leg, 3) Heel of the stance leg comes off the ground, 4) Free leg does not fully return to the starting position Measurement Recorded: Maximal distance obtained for each diagonal for each leg (centimeters) Cumulative Score: LL = Limb Length, A = Anterior, PM = Posteromedial, PL = Posterolateral {[(A + PM + PL/(LL x 3)] x 100} Posterolateral Posteromedial Anterior **Correction** Toes should be at the center of the Y (NOT the heel, as shown) Page 4
Single Leg Squat Patient stands on one leg, without upper extremity support, hands at hips or out to side for balance. Patient squats down to a maximal depth on one leg and returns to standing. The patient is not allowed to brace the opposite leg against the squatting leg or the floor at any point during the squatting effort. Measurement Recorded: Angle of knee flexion at maximal squat depth per leg Retro Step-up Patient stands in front of a step, places test leg back onto step with neutral foot rotation, and shifts back into hip and knee flexion. The front leg is straight, with the toes pulled up off the ground and knee extended, to avoid compensation at the knee or ankle with the non-test leg. The patient presses through the step leg to concentrically raise themselves up the height of the step, and then slowly lowers down eccentrically to a controlled touch of the opposite heel. Both phases must be controlled without compensation or uncontrolled acceleration. The patient progressively moves up higher steps, testing each limb, until failure. 3 attempts to master each step height are allowed, however, if the step is successfully completed on the first trial, no more efforts are necessary at that height. Measurement Recorded: Maximal step height achieved per leg (inches) Note: Test can be normalized to leg length Page 5
Level II Functional Pre-requisites: Lower Extremity Physical Performance Testing Return to Sport (Level II): Muscular Endurance, Power 1) All Level I tests 85% of uninvolved side or maximal value 2) 2 leg squats: 90 knee flexion x 20 reps with good trunk and lower extremity alignment control Squat Repetitions to Fatigue Patient performs a single limb squat with no hand support to an angle of 60 degrees knee flexion. A chair or stool is used to mark this squat depth for testing purposes. The patient then completes squatting repetitions at a tempo of 60bpm (1 squat every 2 seconds), going from an unlocked knee position in upright stance to the 60 degree mark, lightly touching the buttocks to the stool. Patient completes as many squats as possible over a 2 minute interval following the guidelines of: 1) staying on tempo 2) achieving full squat depth 3) maintaining normal L/E and trunk alignment (requiring 2 cuing episodes) 4) Pain 3/10 at the involved joint 5) Fatigue or cramping Measurement Recorded: 1. Number of squatting repetitions completed in 2 minutes per leg 2. Perceived Exertion (0-5 point scale) *Squats that deviate from ideal alignment or depth are not counted toward total Page 6
Single Leg Hop The patient stands on one leg and leaps forward as far as possible, sticking the landing on one leg with good knee/hip flexion and balance control. The test is void if the patient double-hops on the landing, collapses into knee flexion and steps onto the opposite leg, or steps off to the side before demonstrating adequate balance control. The goal is to achieve maximal distance. Measurement Recorded: Maximal distance obtained (toe to toe) in meters per leg Page 7
Level III Functional Pre-requisites: Lower Extremity Physical Performance Testing Return to Sport (Level III): Power 1) All Level I tests 85% of uninvolved side or maximal value 2) All Level II tests 85% of uninvolved side 6M Timed Hop A 6M distance is marked within the clinic space with adequate clearance to decelerate beyond the finish line. The patient starts standing on one leg and hops as quickly as possible on that leg all the way through the finish line with time recorded. The goal is to achieve the quickest time possible. Measurement Recorded: Quickest time achieved per leg (nearest tenth of a second; ie. 2.3 seconds) Triple Cross-over Jump The patient completes a series of 3 consecutive jumps on one leg, crossing a 12 cm wide center line with each effort, and sticking the landing from the final jump. The goal is to achieve maximal distance. The pattern of movement is zig, zag, stick. The test is void if the patient pauses between hopping efforts, double-hops on the landing, collapses into knee flexion and steps onto the opposite leg, or steps off to the side before demonstrating adequate balance control upon the final landing. Measurement Recorded: Maximal distance obtained (toe to toe) in meters per leg Page 8
Data Collection/Reporting All test values are recorded and compared side to side to calculate a limb symmetry index (LSI), which is expressed as a percent return of function of the involved limb compared to the uninvolved limb. A value of 85% LSI has been cited as abnormal (Noyes AJSM 1991). Patients complete only portions of the test that are appropriate for their rehabilitation needs, injury status, or post-operative status. Portions of the test that have been previously mastered ( 85% LSI) need not be re-tested. A qualitative assessment at the end of the test is useful to describe movement control, degree of challenge/exertion, and any symptoms reported with each activity. The physical performance test is a useful tool for therapists to make both qualitative and quantitative observations of a patient throughout the rehabilitative process. The outcomes of this test are useful to refine and progress subsequent therapy, educate and motivate patients, and communicate critical status information to the treating physician for determining appropriateness of return to activity. These outcomes also help team members appreciate the role of the functional return of strength, balance, power and endurance in overall patient outcomes, for both operative and non-operative care. Page 9